When am I entitled to appeal my insurance company over a denial of care?

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When am I entitled to appeal my insurance company over a denial of care?

Answers From Experts & Organizations (1)

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Lisa Zamosky

Health Insurance, Health Care and Consumer Affairs

California Healthline

53 Answers
107 Helpful Votes
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There are a number of circumstances under which you're entitled to appeal your insurer's decisions. You can appeal if your insurer:

Denied payment for your care
Ruled that your care was not medically necessary
Said that you're not eligible for the benefit in question
Claimed that your treatment is experimental
Claimed that you have a pre-existing condition (when your plan does not cover them)

By law, your insurer must review your appeal and make a determination within certain timelines:

72 hours for denials of urgent care.
30 days for denials of nonurgent care you have not yet received.
60 days for denials of service you have already received.

If your insurance company has been paying for your care and made a recent decision to stop, it's always worth asking that it continue paying for your treatment until a determination on your appeal has been made.

This answer should not be considered medical advice...This answer should not be considered medical advice and should not take the place of a doctor’s visit. Please see the bottom of the page for more information or visit our Terms and Conditions.

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